Private Consultation Intake Form
Owner Information
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dog Information
Dog's Name
*
Dog's Age
*
Dog's Breed or Best Guess
*
Sex
*
Male
Neutered Male
Female
Spayed Female
How long have have you owned your dog?
*
Where did you get your dog?
*
Behavior History
What are the main issues you want help with? (Be specific)
*
When did these behaviors begin?
*
Have these behaviors gotten better, worse, or stayed the same?
*
Where do the issues mainly occur?
*
Inside Home
Outside Home
On Walks
Around Family
Around Strangers
Around Dogs
Other
**IF OTHER, PLEASE DESCRIBE
Have you already tried to fix the issue(s)?
*
Have you worked with a trainer or behavior professional before?
*
If yes, please describe who you worked with and what was recommended:
Environment & Lifestyle
Who lives in the home with the dog?
*
How much daily exercise does your dog currently get?
*
Very little
1 short walk
1 long walk
Multiple walks
Off leash time
Structured training
Other
**IF OTHER, PLEASE EXPLAIN
What kind of equipment do you currently use on walks?
*
Safety & Severity
Has your dog ever bitten a person? (Nips are bites)
*
No
Yes, no medical attention needed
Yes, broken skin
Yes, drawn blood
Yes, needed medical attention
Has your dog ever bitten a dog? (Nips are bites)
*
No
Yes, no medical attention needed
Yes, broken skin
Yes, drawn blood
Yes, needed medical attention
Does your dog guard food, toys, space, or people?
*
**IF YES, PLEASE EXPLAIN
Your Goals
What would a successful outcome look like for you?
*
Why is now the right time to get help?
*
Scheduling
Consultations are 90 minutes and done on Mondays, Tuesdays & Thursdays. Which days typically work for you?
*
Mondays
Tuesdays
Thursdays
Agreement & Expectations
Please read and confirm:
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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